Author + information
- Anna C. Kydd, MD,
- Duncan McNab, MD,
- Patrick A. Calvert, MD, PhD,
- Stephen P. Hoole, DM,
- Sushma Rekhraj, MD,
- Horst Sievert, MD,
- Leonard M. Shapiro, MD and
- Bushra S. Rana, MD∗ ()
- ↵∗Papworth Hospital, Papworth Everard, Cambridge CB23 2RE, United Kingdom
A prominent right atrial Eustachian ridge (ER), which inserts into the roof of the fossa ovalis (FO), can impede successful placement of a patent foramen ovale (PFO) closure device, resulting in residual shunting. This can be mitigated by selecting a more flexible or smaller device, illustrated by the following clinical case. Although the precise prevalence is unknown in a consecutive series of 73 patients undergoing PFO closure in our institution, over 18 months we observed this type of anatomy in 23 patients (32%), using 3-dimensional transesophageal echocardiography (3D TEE). A 3D TEE assessment is usually performed pre-procedure to allow us to plan an implant strategy; however, we have a range of device types and sizes available at the time of PFO closure. If a prominent high ER is present, we are in a position to consider a smaller and softer device that conforms to this anatomy and will rest flush with the septum.
A 45-year-old woman suffered an embolic stroke. She underwent PFO closure using a 25-mm Amplatzer PFO occluder device (St. Jude Medical, Inc., St. Paul, Minnesota) (Figure 1A). At 6 months, a routine agitated saline transthoracic echocardiography study showed a significantly larger shunt than pre-PFO closure. 3D TEE demonstrated residual shunting from the superior aspect of the left atrial disc (white arrow). The right atrial (RA) 3D TEE view revealed a prominent ridge of solid tissue, the ER (black dotted line), preventing the RA disc (white dotted line) from resting flush on the FO because the FO was partially obscured at its anterosuperior border by the high insertion of the ER. Flow was seen from the inferior edge of the RA disc through the PFO, which was “held open” by the “rigid” device.
A further example of this anatomy is shown in Figure 1B. To achieve complete PFO closure, we found either a softer more compliant device (Gore Helex septal occluder, W. L. Gore & Associates, Inc., Flagstaff, Arizona) (Figure 1C) or a smaller device where the left and right atrial discs can be placed independently (Premere device from St. Jude Medical, St. Paul, Minnesota) (Figure 1D) to be better suited. The identification of a prominent ER is essential to guide optimal device selection.
Please note: Dr. Sievert has received study honoraria from Abbott, Access Closure, AGA, Angiomed, Aptus, Atrium, Avinger, Bard, Boston Scientific, Bridgepoint, Cardiac Dimensions, CardioKinetix, CardioMEMS, Coherex, Contego, Covidien, CSI, CVRx, EndoCross, ev3, FlowCardia, Gardia, W. L. Gore & Associates, Guided Delivery Systems, InSeal Medical, Lumen Biomedical, HLT, Lifetech, Lutonix, Maya Medical, Medtronic, NDC, Occlutech, Osprey, Ostial, PendraCare, pfm Medical, Recor, ResMed, Rox Medical, SentreHeart, Spectranetics, SquareOne, Svelte Medical Systems, Trireme, Trivascular, Venus Medical, Veryan, and Vessix. Dr. Rana has received lecture fees from W. L. Gore & Associates. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation